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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603771
Report Date: 10/03/2024
Date Signed: 10/08/2024 09:55:09 AM

Document Has Been Signed on 10/08/2024 09:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:WESLEY HEALTH CENTERS-SKID ROW RES CARE FACILITYFACILITY NUMBER:
198603771
ADMINISTRATOR/
DIRECTOR:		VANDERHIDER, DONAHUEFACILITY TYPE:
740
ADDRESS:601 E 5TH STREETTELEPHONE:
(818) 731-4317
CITY:LOS ANGELESSTATE: CAZIP CODE:
90013
CAPACITY: 48CENSUS: 0DATE:
10/03/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Alvaro Ballesteros (Licensee) &
Donahue Vanderhider (Administrator)		TIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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COMP II by CAB successfully completed
Facility Type: RCFE - CCE
Application Type: INTL
Capacity: 48
Census : 0
Method: Telephone call with CAB

COMP II Participants: Alvaro Ballesteros (Licensee), Donahue Vanderhider (Administrator), & Tammy Edwards,(Analyst).
Licensee & administrator participated in COMP II via Telephone call with CAB Analyst. Identification
of licensee/administrator was verified by confirming driver’s license numbers. During COMP II,
licensee/administrator confirmed the understanding of Title 22. Component II was successfully
completed. Licensee/administrator were advised to email signed LIC 809 with copy of photo ID to
CAB.

During COMP II, CAB analyst confirmed licensee's/administrator’s understanding of following
areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Tammy Edwards
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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